The Swedish experience and headache of tobacco harm-reduction

When news spread in the 1560s that Queen Catherine de' Medici of France was suffering chronic migraines, a man named Jean Nicot cured her. He recommended she take clay tobacco (snus/snuff) nasally. Legend has it that as the queen’s headaches began to ease it created a culture of using this plant for medicinal, spiritual and social purposes.

This was considered so revolutionary that the chemical in tobacco, nicotine, was named after Nicot.

Scott Springfeldt, director of the tobacco museum in Stockholm, said after this discovery snuff usage was popular with the upper class in the 1700s and was taken nasally.

He was addressing a South African media contingent visiting Sweden for a knowledge sharing experience this week. It was to consider whether a world without cigarettes was possible and what South Africa could learn from the Swedish experience — the Swedes predominantly use snuff instead of cigarettes, dramatically reducing the number of smokers, on its way to being smoke-free and a model country for harm reduction.

“It was an expensive product and a symbol of status among wealthy and influential people. They would get snuff boxes with gold and expensive material, some even used rhino horns, little combination lockboxes or seashells to stand out. This reinforced their position in society, it was more than fashionable.

“More people planted tobacco at their homes and processed it however they wanted. They would add salt, spices or alcoholic spirits to make it interesting. People were creative in how they used it. Its relevance drastically changed with the emergence of the French Revolution, because it was heavily associated with nobles, it became a political and social attitude.

“Society was walking away from anything that reminded them of oppressive rule. It was so bad that people would get assaulted if they were seen in public with a snuff box,” said Springfeldt.

As snuff use was declining, during World War 2 a new product infiltrated the market: cigarettes. “It was made popular by the men who went to war, people started seeing their heroes smoking a cigarette and they followed. Unlike snuff, it represented freedom, it was a modern product and people associated it with equality.”

While snuff still hung in the balance and the state-owned Tobacco Monopoly Company, which mass produced it, was on the brink of a shutdown, a damning US surgeon general's report on tobacco was published in 1964. The landmark report warned users smoking cigarettes contributed to the deterioration of their health and was a killer. This became a turning point for the company as the Swedish market started to transition back to snuff — the company did not have to shut down after all.

“Snuff was mostly used by men. As years went by, pouches were created and women started using it as it had a better appeal. It was convenient and cleaner, they didn’t have to mould the snuff with their hands,” Springfeldt said.

Though smoking has been proven to be detrimental to the health and wellbeing of users and those around them, tobacco remains a big business. Instead of quitting, those hooked seek less harmful options to keep up with their cravings and habits.

In a move to attract a new market of smokers, convert traditional cigarette smokers and promote harm reduction, tobacco giant Phillip Morris International (PMI) two years ago acquired the Swedish Match company. Based in Stockholm, it is one of the big producers of smoke-free products — Zyn nicotine pouches.

Swedish Match vice-president of communication Patrik Hildingsson said people in Sweden still consume nicotine, but they do it without combustion: inserting snuff pouches or flavoured nicotine products between the gum and upper lip.

Cigarette smoking was made popular by the men who went to war, people started seeing their heroes smoking a cigarette and they followed. Unlike snuff, it represented freedom, it was a modern product and people associated it with equality

—  Scott Springfeldt, director of the tobacco museum in Stockholm

Hildingsson said this unique style of using tobacco was the reason the country is on its way to gaining an international smoke-free status of less than 5% consumption.

According to the World Health Organisation’s (WHO) standards, a smoke-free society has less than 5% of its population smoking. On the back of this, EU member states are tasked to reach this target by 2040.

Snuff has over the years positioned itself as an integral part of the social and cultural life of the Swedish people.

“Since the legend that the queen was healed from her terrible headaches, the Swedish people started to use it for different reasons, some used it as a medicine and believed it had powers,” said Hildingsson.

The low prevalence of smoking in the country can be attributed to the male population that smokes less than women.

According to a 2021 Euro barometer 506 report, smokers in Sweden smoke five or fewer cigarettes a day. Hildingsson said though the country had fewer smokers, this was not a result of harsh tobacco control measures or harm reduction campaigns, but a consumer preference.

South Africa can learn from the Swedish experience the power of consumer choice and access to less harmful but still appealing products.

“Nicotine is a complicated thing, how much of it one is exposed to depends on different things.

“A direct comparison of nicotine exposure between different products is not a straightforward [thing]. For example, only about a quarter of nicotine in snuff is extracted while 95% of nicotine in e-liquid is extracted.

“The amount of nicotine a user of a product is exposed to depends on, among other things, a product's characteristics, way of usage and user individual traits,” said Hildingsson.

A WHO report in 2008 said: “Among the smokeless tobacco products on the market, products with low levels of nitrosamines, such as the Swedish snus, are considerably less hazardous than cigarettes.”

PMI Sub-Saharan Africa vice-president Branislav Bibic said acquiring the oral smokeless products manufacturer was a great move towards encouraging harm reduction.

It has expanded its portfolio of smoke-free alternatives and accelerated its vision of a smoke-free future. “By acquiring Zyn, we gained access to a rapidly growing market segment and a product with a stronger consumer base. This acquisition allowed us to strengthen our position in the smokeless nicotine category.

“It has helped accelerate our shared vision of a world without cigarettes and lead the transformation of the industry,” said Bibic.